Abstract
The increase of every creature is constantly being checked by unperceived agencies; and... these same unperceived are amply sufficient to cause rarity, and finally wrote Charles Darwin inThe Origin of Species.1Today's competitive health care environment is pointedly Darwinian, but its hostile agencies are amply apparent. An unspoken, subversive subtext anticipates of the fittest—we all know the fate of the dinosaurs. Nowadays, as health policy experts muse about which health care institutions risk extinction, major teaching hospitals are not infrequently called dinosaurs. Underlying this speculation is the assumption that price, virtually exclusively, drives hospital competition. For many reasons, most major teaching hospitals are undeniably costlier than nonteaching facilities.2But what about broader societal contributions, such as education and research, and what about quality of care? See also p 485. In the natural world, wily ways—speedy and clever responses to external threats—provide primal survival
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